Provider Demographics
NPI:1891818555
Name:TATE, ANGELA GAIL (MCD/CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:GAIL
Last Name:TATE
Suffix:
Gender:F
Credentials:MCD/CCC-SLP
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:GAIL
Other - Last Name:TATE-WASHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCD/CCC-SLP
Mailing Address - Street 1:3400 MCCLURE BRIDGE RD G 701
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8751
Mailing Address - Country:US
Mailing Address - Phone:678-957-1012
Mailing Address - Fax:678-957-1013
Practice Address - Street 1:3400 MCCLURE BRIDGE RD G 701
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8751
Practice Address - Country:US
Practice Address - Phone:678-957-1012
Practice Address - Fax:678-957-1013
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP 5334235Z00000X
GA006491235Z00000X
GASLP006491235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA169808036DMedicaid
GA202I153414Medicare UPIN